Shermin Davis Appointment Request Form

Shermin Davis Appointment Request Form
Please be aware that at the moment there is a waiting list for new patients to be seen in the office. If applicable, one option that is available now is guided journaling with Shermin. Find out more here.
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Zipcode *
Date of Birth *

Month Day Year
Date Date Picker Icon
Referred By *
Main Concern
Your Availability *
Dates, Days and/or Times that work for you
Meeting Options (check all that you are interested in) *

In Office Face to Face Online Phone Session Journal Therapy
Insurance *
Other Insurance / EAP Info
Insurance ID # *
Type NA if paying privately
** PLEASE NOTE: At the moment this office is not able to file insurance claims. Please check the option that applies for you below. *

I want to be notified and schedule an appointment when my insurance can be utilized I want an appointment earlier and will pay privately until my insurance can be utilized I want to check if I qualify to participate in guided journaling with Shermin now. More info here: https://www.shermindavis.com/SecureJournalingPortal.en.html
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